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**Note to Requester: Retain a copy of this request for your files. If you eventually need to file a Request for Review with the Public Access Counselor, you will need to submit a copy of your FOIA request.**

Name and Address of Public Body Receiving Request:

Date Requested:

Request Submitted By: ___ E-mail ___ U.S. Mail ___ Fax ___ In Person

Name of Requester:

Street Address:

City/State/County Zip (required):

Telephone (Optional):

E-mail (Optional):

Fax (Optional):

Records Requested: *Provide as much specific detail as possible so the public body can identify the information that you are seeking. You may attach additional pages, if necessary.

Do you want copies of the documents?        YES   or  NO

--Do you want Electronic Copies or Paper Copies?

--If you want Electronic Copies, in what format?

Is this request for a Commercial Purpose?     YES or    NO

(It is a violation of the Freedom of Information Act for a person to knowingly obtain a public record for a commercial purpose without disclosing that it is for a commercial purpose, if requested to do so by the public body. 5 ILCS 140.3.1(c)).

Are you requesting a fee waiver?         YES     or     NO

(If you are requesting that the public body waive any fees for copying the documents, you must attach a statement of the purpose of the request, and whether the principal purpose of the request is to access or disseminate information regarding the health, safety and welfare or legal rights of the general public. 5 ILCS 140/6(c)).